In his compelling work, E. Fuller Torrey described in detail the four basic components that make therapy successful across cultures. Torrey explained through his rigorous research each of the four components: a shared worldview, the personal qualities of the therapist, the expectations of the client, and an emerging sense of mastery. Torrey used the analogy of a horse and canary pie. The four components are analogous to the horse, and techniques are analogous to the canary. Successful therapy then, can be obtained with more horse, and less canary. Torrey clearly indicates that all psychotherapy is at its best, on the same scientific plane regardless of orientation and culture. Torrey weaved a complex web of pluralistic ideas regarding effective therapeutic practice. The book Witchdoctors and Psychiatrists was published in 1986 as a challenge to the profession of psychotherapy and counseling to embrace all forms of assistance and healers, in a grand endeavor to treat more efficiently and effectively all clients in a multicultural context. It remains a critical robust examination of the salient issues in counseling and psychotherapy today.

Introduction

In his seminal work Witch Doctors and Psychiatrists, E. Fuller Torrey challenges the notions of American “universal” psychotherapy and the American/ Western-European counseling culture as a whole. Many were impressed with the extensive field research Torrey conducted in writing this short book. Many were also impressed with the constant examination of his “ethnocentrism and biases” which he claims, “lurk at the periphery of my own vision” (Torrey, 1986; pp. xiv).

After reading this book, it seems obvious that urban psychotherapists have much more in common with our fellow indigenous healers. Before reading this book, some had an inkling of the operation of indigenous mental health practices, but many were not aware of the extensive rituals, the use of religion and spirituality, and the shared worldview held with clients. Like the indigenous healer, the American psychotherapist uses similar rituals, use of secularity, and shared worldviews.

It was found amusing that the very first line, of the very first chapter, was a great example of what Torrey was speaking of in terms of expectation of the client or “emotional arousal.” The first line reads, “Psychotherapy, the world's second oldest profession, is remarkably similar to the first.” Many were offended with this bold statement because it aroused thoughts of a therapist “soliciting” services.
Many agreed with Torrey that our ethnocentrism and our conviction that Western psychotherapy is not universally valid. Some strongly agree with Torrey's research findings that there are four underlying basic components that make all forms of psychotherapy effective.

The Components of Psychotherapy

It is exciting to know there are rules to this art we call counseling. Like any art form, there are boundaries and rules which to abide by, and on occasion, to break. The four components of psychotherapy are like the basic rules of art, if a helper does not possess these components, like an artist, will not be as successful or as knowledgeable to create masterpieces. In therapy, that could mean ethical conduct violation, damaging a client, or professional incompetence. The four components Torrey outline are: a shared worldview, the personal qualities of the therapist, the expectations of the client, and an emerging sense of mastery.

Torrey (1986) states, “the techniques used by Western psychiatrists are, with few exceptions, on exactly the same scientific plane as the techniques used by witchdoctors” (pp.11). If this holds to be true, then any technique in any culture of healers (with few exceptions) is equal in effectiveness to that culture. Wagner (1981) considers each culture a specific manifestation or example of he human condition [every culture as such, is equivalent to every other one (Wagner, 1981) as cited in Inouye & Pedersen, 1985]. Torrey and Wagner are saying the same thing but in different ways. Many agreed strongly with Wagner and if his ideas hold true, then the techniques and theories used by indigenous psychotherapists are equally valid when compared with techniques and theories of Western psychotherapists.

A Shared World View

The therapeutic effect of naming a disease or illness or symptom is what Torrey calls the Principle of Rumpelstiltskin. The answer to the question “how close will a therapist be practicing from where he/she obtained a college education” could be, “not far from where I grew up.” If a counselor does not share a small portion of a worldview with his clients, according to Torrey, he or she will not be as successful in therapy with these clients. There is contrary evidence to Torrey‚s idea of a shared worldview in the writing of Carl Rogers (1986, 1987) and Sue & Sue (2008).

According to Rogers (1987) the core therapeutic conditions [unconditional positive regard, warmth, and congruence] have been put to the test in a wide variety of situations with very divergent groups, different cultures, and different nations (Rogers, 1987d; as cited in Corey, 2008, pp. 249). As beginning counselors search for a solid orientation from which to practice, do we choose to believe in Torrey‚ characteristics of a effective counselor or Rogers‚ growth conditions? Maybe both? Unlike Torrey’s writings, Rogers believed that the therapeutic relationship and the client’s resources were the crux of successful therapy (Rogers, 1989).

A shared worldview with clients is important for successful therapy to occur. Some fear that current counseling educational programs and practitioners do not emphasize a shared worldview, and the doctrine of psychopathology has become more important to graduate programs. We agree most with the definition by Koltko-Rivera (2004): a worldview is a set of assumptions about physical and social reality that may have powerful effects on cognition and behavior (as cited in Sue & Sue, 2008). These powerful effects allow people to live in the same world, yet to perceive the world in different shapes. Torrey points out these shapes give clues to causation of mental illness. If these common thoughts on causation are congruent, then treatment will have a better chance of success.

The Medicinal Mensch

A simple definition of mensch is a person of honor or integrity. What a great definition for people in the helping professions to emulate. Torrey has great examples in his book of the personality qualities various helpers possess. One study included in this book by Strupp and Hadley provides serious contradictory information for practitioners. There results suggested that the positive changes experienced by a group of patients were attributed to the healing effects of a benign human relationship, not educated professionals (as cited in Torrey, 1986; pp 45).

It is obvious and common sensical that therapeutic influence or “positive changes,” can be obtained from interaction with daily life. One can have therapeutic interaction such as, one can talk about their problems to their mate (catharsis), one can exercise, (just as good as Prozac), and one can eat healthier foods (activated self esteem). I think the path to become a medicinal mensch starts long before a person decides to become a counselor. Carl Rogers says something similar, “intellectual training and the acquiring of information has, I believe, many valuable results- but becoming a therapist is not one of those results” (as cited in Torrey, 1986). The most successful therapists, we believe, live a certain type of lifestyle. We could call this the therapeutic lifestyle. We don’t know what all it entails but we could speculate what Freud, Rogers, Adler, May, Frankl, Perls, Glasser, Skinner had in common in terms of how they lived outside of the therapeutic realm.

Client Expectation

This book has raised the awareness of many counselors in many ways but more so in the area of client expectation and increasing emotional arousal. It seems the concepts of the self-fulfilling prophecy and the placebo effect have been used in psychotherapy for quite some time. In a recent Scientific American magazine, there was a report, which found “the placebo effect works even when patients know they are receiving a placebo.” The report went on to give great advice to health insurers, “cover sugar pills” (Hackett, 2011). Torrey identifies that patient expectations are a powerful therapeutic tool.

It is a healing idea that increasing a client’s emotional arousal can have big payoffs. One thinks of the greater benefits of Psychodrama therapy originated by Moreno (1889-1974). In psychodramatics, a client is thrust into role-playing, creativity, and physical action. Are the underpinnings of this therapy investing a client in their work, or to put it another way, to increase their emotional arousal? The idea that therapeutic change can be obtained by increasing faith engenders an expectation of cure and motivation in the client. Torrey reports that the long, drawn out traditional ceremonies, and paraphernalia used by indigenous healers is nothing more than a therapeutic ploy to increase arousal.
Lastly, the raising of client expectations and emotional arousal cannot be guaranteed, or easily obtained. It is therefore incumbent upon therapists to increase their reputation as competent healers in their communities. How does one do that? Imagine a notable actress who is regarded as a great talent in film who decides to pursue her true dream and becomes a therapist. Assuming she is a decent counselor, would her fame increase arousal in clients? Would her reputation (if positive) contribute to her ability to affect change in clients? According to the findings of Torrey and many others, she would be effective at increasing arousal and possibly great therapeutic change. Charisma is often a potent therapeutic mechanism.

Techniques of Therapy

In Witchdoctors and Psychiatrists Torrey states, “It is not that the techniques have no [sic] therapeutic value in and of themselves, but rather that their value is negligible compared with the four basic components” (1986, pp.79). Carl Rogers and the current body of research would obviously be in agreement with this point. But Torrey is pointing to something bigger than techniques, or relationship or curative factors. He is pointing to the ethnocentricity of America, specifically in mental health. Is it true, that the current techniques used by American psychotherapists are negligible?

Torrey points out that therapists everywhere believe that their techniques are scientific‚ and that other therapists use “just magic”‚ (pp.79). We do believe if an indigenous healer were to call American therapy techniques “just magic”, the psychological community would be outraged because American philosophy is premised on empirical research, not magic. Torrey goes on to make a robust case that the idea of magic or spirituality, which is at play in some indigenous healing ceremonies, are exactly what raise the client’s expectation. Could the use of magic or spirituality or psychopharmacology or psychological techniques be nothing more than tools to raise expectation?

The two techniques proposed as the most important therapeutic tools in other cultures are confession, and suggestion. Clients who are able to verbalize their experiences through confession gain a sense of mastery over their issues. The school of psychoanalysis called this technique catharsis. A word often heard is “abreaction.” This is different than the term “reaction” because during an abreaction a client physiologically and psychologically relives a painful or traumatic experience. Torrey cites that both Indian groups and Mexican curanderos use confession and abreaction in their ceremonies.

The second technique that is stated as underused in the Americas is suggestion. In the counseling literature there is strict emphasis on providing non-directive counseling i.e. no suggestion. Torrey states that another form of suggestion is sacrifice. It would be interesting to see an American therapist performing sacrifices in his office or at a site visit. Alfred Adler saw payment as a sacrifice.

In the directive counseling approach, arousal is obviously raised. A so-called “expert” says X, Y and Z and the client, believing in the power of the expertise, which increases hope that if they complete X, Y and Z, they will be cured or made well. There are several reasons Torrey gives as to why suggestion is not as popular in America. One reason is both therapists and clients hold different theories of causation, symptom removal instead of curing illness, and suggestion may not be compatible with Protestant ethic. One believes the latter would be the hardest to overcome seeing how deeply engrained this value is in Americans. C. G. Jung would call this engrained value a cultural complex.

Torrey spoke of altered states of consciousness and these have been seen as very intriguing in terms of their therapeutic value. The spectrum of consciousness consisted of seven states: Full Consciousness, Emotional Arousal, Guided Imagery, Light Hypnosis, Deep Hypnosis, Trance, and Disassociation. What is fascinating about this description is an ability to depart from full consciousness. Imagine a severely traumatic experience occurs, causing a person’s mind to fracture and dissociate. Can a therapist conduct successful therapy with a client who has dissociated? The answer depends on the competence and experience of the clinician.

Some of the other notable techniques Torrey points out as being used in other cultures around the world that are idealized in Western Psychiatry are the psychoanalysis, conditioning, and group and family therapy techniques. It is a bit discomforting to acknowledge that Western mental health philosophy may be flawed, and possibly obsolete! Regardless of our limitations, as individuals we choose which theories to follow and which techniques to apply. Rosanne Cash, the daughter of the great musician Johnny Cash, has said this about the art of musicality, "Style is a function of your limitations, more so than a function of your skills.” There are no techniques or theories that work in every situation with every client. But, if Ms. Cash is correct then it is not a matter of techniques and theories, but a matter of finding one’s unique style and working within the parameters of one’s limitations.

We would like to make three interesting points before closing the review on this section. Enhanced consciousness, what is it, and how do you know when you obtain it? In your backbone you feel a pointed something and it works its way up. The base of your spine tingling, tingling, tingling, tingling. Then [the energy] makes your thoughts as nothing in your head.‚ This was the description given by a Kung healer, a bushman in the Kalahari Desert. I find it sufficient due to its simplicity to explain how it feels to reach such an elevated state. Second, the passage goes on to state how in other cultures, healing is an integrated and enhancing force, not just offering cures with the application of medicine. We find this definition of healing necessary and satisfactory.

Lastly, counselor educator programs emphasize the acknowledgment one’s biases, blind spots and cultural values. Torrey points out the cultural goals of Western therapy and the argument could be made that these goals reflect Western bias, blind spots and values. A few Western values are achievement, independence, responsibility and rational thinking. Some goals are insight, personal efficiency, and social efficiency. It is important that counselors with a Western orientation, do not cross ethical lines by the imposition, on clients of different orientations, of their personal and professional values and beliefs. Torrey points out that these values and beliefs are merely apart of the zeitgeist, or spirit of the time. Some day, the current values and beliefs will be regarded as part of the life of a culture and categorized as cultural artifacts.

Toward the Future of Psychotherapy
The future of psychotherapy remains bright. We have seen a new paradigm, one once thought unimaginable. It will take creativity, innovation and benevolence to move this profession forward, past our current state of affairs and beyond. Torrey (1986) declares it is time we grow beyond the idea that therapists in other cultures lack substance of mind (pp. 115). In other cultures, there is not a wide split between mental health and religion/spirituality. The philosophy of Abba Wolde Tensae, a priest/ healer in Ethiopia who after curing clients of zar spirits, takes no credit for the deeds done, but merely states, he was only God’s tool‚ (pp. 118).

Will the profession of counseling and psychotherapy take such a drastic turn as to de-secularize mental health? Not any time soon, but we do believe there will be, and currently is, a strong urge from clients to integrate all forms of self in healing. A fascinating part of this book was the objective description of an American West coast psychotherapist. It is ironic that psychotherapy could be described from such remote terms, and clearly put psychoanalytical therapy in perspective. The description of a college diploma, explained as a tool to raise client expectation merely as “requisite paraphernalia” was summed up as “Framed pieces of paper on the wall” (pg. 130). It is exactly this type of remote, depersonalized, unbiased perspective that allows for greater appreciation of cultural influence on therapy and its distributors.

The curandera’s confidence that Torrey described was impressive when he reported a curandera would simply take the patience’s pulse and announce a diagnosis. Wow! What a leap of faith. We found interesting the explanations of the multiple functions and purposes which cultural beliefs and values play in each culture. Torrey described some Hispanic values and beliefs about causation/ cure as regulatory functions, an enforcement of behavior, an overriding function, and a way to “prove” the depth of cultural belief. These points above many can be translated in any cultural belief system. According to a learning theorist, if cultural beliefs and values did not have a purpose they would be unlearned, satiated and replaced. The functions of cultural values and beliefs serve a purpose.

An immense amount of relevant items in this brief book remain salient. This book has helped many question the so-called “differences” between healers in various cultures. These differences are not vastly distinct as once thought, but they are similar and have comparable underpinnings. We believe that the four components of psychotherapy delineated by Torrey are at play during therapy and at play during relationships of any degree. Many look at Torrey‚s ideas both as a framework for understanding the therapy process and as a framework of cultural influence and achieving power through this influence.

We agree with Torrey that in order to be treated appropriately, people in a multicultural context must be treated from within the framework of their culture. It almost seems unethical to treat somebody from a different culture through the framework of another culture. It noted in the margins of my book there is a recipe for unethical, unsuccessful therapy. The therapeutic relationship will not be fostered if the counselor does not share a common worldview, has a non-therapeutic personality, has an inability to increase expectation, and lacks the ability to inspire a client’s sense of mastery. I learned it can be valuable to nurture these qualities as a person but it can be therapeutic as a counselor. These qualities are not sophisticated or esoteric, but are accessible by all.

Torrey uses the analogy that successful psychotherapy is like a horse and canary pie, the horse being the components, and the canary being techniques. What many have come to understand is that Torrey believes that techniques are not as important as the basic components of psychotherapy. Torrey implies fighting over which techniques work best is a silly and pointless endeavor. Torrey comes back around to use his initial analogy of the second oldest profession, “Saying that psychotherapy does not work is like saying that prostitution does not work; those enjoying the benefits of these personal transactions will continue doing so” (pp. 198).

Conclusion

Lastly, and most importantly, what many have come to understand is to impose services on a client from a multicultural context from the framework of another culture is not considered best practice. Today’s rigid standards for practice and licensure are due to the evolution of the times and ethical guidelines. Torrey states, “No psychotherapist should be allowed to practice without having met minimal standards of competence and character and a system of licensure should be required so that consumers could know who was accredited to practice” (pp. 217).
Many counselors-in-training continue to meet minimum competence and now, according to Torrey, in order to successfully treat clients each must develop and nurture the basic components of psychotherapy.